Case Study: February 2015: Prashant Krishnan, MD

Date: February, 2015

Case Study:

A 63-year-old, male patient presented for an EGD in February 2015. This patient was initially seen in our clinic for iron deficiency anemia. He had undergone transfusion and IV iron therapy. He underwent an EGD and a colonoscopy with a standard, forward viewing scope at an outside facility. The EGD was reported as normal. The colonoscopy revealed some polyps, but no source of bleed. Due to the occult bleed, a capsule endoscopy was performed and revealed active bleeding about 7 minutes into the small intestines. It was unclear what was bleeding and whether the bleed was in the duodenum or jejunum. An EGD with a Fuse endoscope was scheduled and performed.

Procedure Information/Data

In Figure 1, it is obvious in the center camera that there is an active ongoing bleed in either the distal duodenum or proximal jejunum. However, it is not clear what is causing the bleed.

Figure 1

In Video 1, you can see me washing the area but the blood keeps re-accumulating. Although you can see the re-accumulation of blood in the center camera field, it was not possible to find the exact etiology in the center camera field.

Video 1

After significant washing and careful observation, I was able to finally pinpoint the bleeding on the left camera field, as shown in Figure 2. This likely would have been missed with a forward viewing scope.

Figure 2

I was able to finally see two angioectasias actively bleeding in the left camera field, as shown in Figure 3.

Figure 3

It was extremely difficult to get this into view of the center camera to perform therapeutic maneuvers to stop the bleed so I had to essentially stop the bleeding blindly by using the left camera as my guide. In Figure 4, you can see the areas I injected epinephrine and used electrocautery to stop the bleeding. There was no further re-accumulation of blood. I successfully identified the source of the occult bleeding and stopped it.

Figure 4

Conclusions

• This patient had iron deficiency anemia from an occult bleed. He had an EGD with a standard, forwarding viewing scope and colonoscopy with no obvious etiology. A subsequent capsule endoscopy revealed active bleeding 7 minutes into the small intestines, but the etiology was unclear.

• A repeat EGD using a Fuse endoscope was performed. I was able to successfully identify two angioectasias actively bleeding in the left camera field. Since I was not able to get these lesions into the center camera field to perform therapeutic maneuvers to stop the bleeding, I had to essentially stop the bleeding blindly by using the left camera as my guide and by injecting epinephrine and using electrocautery. I successfully identified the source of the occult bleeding and stopped it.

• I feel the identification of the lesions or the ability to stop the bleeding successfully would not have been possible without the Fuse scope. This technology helped me improve the level of care for this patient.

What is Fuse®?

Fuse®, or ‘Full Spectrum Endoscopy®,’ is the latest advancement in colonoscopy. It provides physicians a panoramic 330 degree field of view (as compared to the 170 degree view common with traditional, forward-viewing scopes). This increased field of view provides physicians with the ability to see and detect more abnormalities.